From: Terry Pannkuk
To: ROOTS
Sent: Tuesday, June 15, 2010 1:44 AM
Subject: [roots] FW: Quiz 2 - More Complicated (if you can believe it)

Here’s the original quiz presentation.  I finally succumbed to doing the endo about a year ago, symptoms didn’t
resolve as I feared and I did the surgery a couple of days ago. - Terry

From: Terry Pannkuk
Sent: Tuesday, November 17, 2009 7:32 PM
To: 'ROOTS'
Subject: Quiz 2 - More Complicated (if you can believe it)

Here's another interesting patient I saw today:

5 years ago she had multiple maxillary anterior implants.  When I saw her for consultation I thought she was a
lawn dart victim.  I checked out #7 but findings were equivocal, the tooth tested vital. it was percussion sensitive
but so was #6.  We decided to monitor.  I saw her a year later in 2005, similar symptoms, pulp still vital, but it
wasn't as sensitive as a year earlier.  We decided to continue to monitor.  Here gingival tissues during this period
were inflamed and she was being passed around from periodontist to periodontist and no one wanted to treat her except
the original treating periodontist, but she didn't want to have him treat her (small wonder). She was extremely frustrated.
By 2007 she found a periodontist who did some grafting, her dentist placed some provisionals and she looked a lot better......
only one problem she developed a fistula that traced to the #9 implant.  With all the goofing around with the #9 implant.
the internal threads had been stripped, the cover screw was presumed loose and the consensus opinion was that the internal
implant space was communicating and contaminated.  Some suggested that I do an apico on it (only upside down and place MTA
in the screw hole space and "put it to sleep".  It wasn't part of the restorative plan because of esthetics.  An implant
supported bridge was the new final restorative plan.  I didn't think it would be a good thing to do and suggested that
the new periodontist trephine it out and graft the area.  The compromise plan was for the periodontist to do the surgery
and drill the coronal part of the implant down deeper eliminating the space area.  I thought that was a good plan and
it was done.  A year later the area had healed, but her biting discomfort and sensitivity was isolated to #7.  I finally
decided to treat it a year ago to rule out endo.  Of course she still has the same pain one year later. She had another
graft performed about 3 months ago.  Tooth #7 is moderately percussion sensitive with normal probing depths.

This woman is tired of being sliced and diced. Check out all the attached chronologic photos and radiographs.  Clearly the
implant in the #8 site is probably close to the apex of #7. What would you do?  - Terry